Comparative performance of national civil registration and vital statistics systems: a global assessment

Abstract Objective To assess the current state of the world’s civil registration and vital statistics systems based on publicly available data and to propose strategic development pathways, including priority interventions, for countries at different levels of civil registration and vital statistics performance. Methods We applied a performance assessment framework to publicly available data, using a composite indicator highly correlated with civil registration and vital statistics performance which we then adjusted for data incomparability and missing values. Findings Globally, civil registration and vital statistics systems score on average 0.70 (0–1 scale), with substantial variations across countries and regions. Scores ranged from less than 0.50 in emerging systems to nearly 1.00 in the most developed systems. Approximately one fifth of the world’s population live in the 43 countries with low system performance (< 0.477). Irrespective of system development, health sector indicators consistently scored lower than other determinants of civil registration and vital statistics performance. Conclusion From our assessment, we provide three main recommendations for how the health sector can contribute to improving civil registration and vital statistics systems: (i) enhanced health sector engagement in birth and death notification; (ii) a more systematic approach to training cause of death diagnostics; and (iii) leadership in the implementation of verbal autopsy methods. Four different civil registration and vital statistics improvement pathways for countries at different levels of system development are proposed, that can constitute a blueprint for regional civil registration and vital statistics strengthening activities that countries can adapt and refine to suit their capabilities, resources, and particular challenges.


Introduction
Fundamental to the assessment of population health is accurate and timely information on patterns and trends in human fertility and mortality. 1Almost all countries have a method to record vital events; however, not all have systems which can reliably determine cause of death and many have systems that fail to record all, or even most, births and deaths that occur.In countries with well-developed civil registration and vital statistics systems, the data they provide on vital events are crucial in assisting national policy-makers and administrators with decision-making, in sectoral strategy formulation, and public health policy and planning. 2Given the multisectoral demand for such data, the successful stewardship of countries is thus highly dependent on a functioning national civil registration and vital statistics system which provides reliable and timely vital statistics.
The health sector has a particularly strong need for functional civil registration and vital statistics systems.The recent coronavirus disease 2019 (COVID-19) pandemic has shown us that we need accurate and timely records of deaths and cause of death to assess, for example, the effectiveness of prevention and control strategies.The management and evaluation of disease reduction also requires reliable and timely data on age-and cause-specific mortality from wellfunctioning civil registration and vital statistics systems.The universal commitment of governments in 2015 to the United Nations (UN) sustainable development goals, which depends, in part, on data from vital statistics systems for monitoring progress, has helped highlight the need for reliable, continuous and comparable vital statistics, creating momentum to improve the recording of fertility and mortality data.
The need to know the number of children born every year, as well as the number of people dying and what they died from, has stimulated several global, regional and national responses over the past two decades to strengthen civil registration and vital statistics systems. 3,46][7][8] The primary limitation of these earlier efforts is their lack of comparability arising from their dependence on self-assessment to generate data and information.We present an alternative statistical framework that relies solely on available data to classify countries into categories of civil registration and vital statistics system performance.Based on these classifications, we propose for each category a strategic development pathway with some priority interventions and improvement actions they can undertake to improve their systems' development.
holders.This framework identifies, as parsimoniously as possible, the key elements of a civil registration and vital statistics system which defines best practices for well performing systems.The framework comprises four domains: (i) enabling environment for civil registration and vital statistics; (ii) functioning of the civil registration and vital statistics system; (iii) health sector contributions to civil registration and vital statistics; and (iv) dissemination practices and demand for vital statistics (Table 1).Performance within each domain is measured using a series of indicators listed in Table 1.Three databased outcome indicators were used to reflect system functionality: (i) birth registration completeness; (ii) death registration completeness; and (iii) percentage of deaths with a usable cause available from the companion articles. 9,10We calculated birth registration completeness as registered births divided by the UN World Population Prospects' estimate of live births. 9,11In some countries, the denominator used was the estimates from the Global Burden of Disease database produced by the Institute of Health Metrics and Evaluation. 12Death registration completeness is defined as the extent to which the civil registration and vital statistics system manages to count all deaths that occur in a year; and in many countries it is calculated using the Adair-Lopez empirical completeness method, which estimates completeness of death registration using a statistical model and several covariates. 10,13In countries where the empirical completeness method is less accurate because of high death rates due to acute immunodeficiency syndrome or violence, conflict and war, estimated deaths are used as the denominator. 11 calculated the percentage of deaths with a usable cause as the percentage of estimated total deaths that have a cause as per the International Medical Certificate of Cause of Death, and for which the assigned cause is not classified as a nonspecific or garbage code. 14

Data sources
6][17][18]  For each domain in the performance assessment framework, we estimated a predicted adjusted overall assessment score based on a statistical model of the functional relationship between the external summary score and the adjusted overall assessment score for countries with available data.Details of this regression model and its predictive validity are available in our online repository. 19ased on the adjusted overall assessment scores across all domains of the performance assessment framework, all 194 WHO Member States were classified into four performance levels (Box 1).
We chose the threshold values of each performance category as follows: (i) high performance systems are those where the adjusted overall assessment score was within 90% of the maximum observed (excluding predicted) adjusted overall assessment score attained by a country with more than one million inhabitants; (ii) moderate performance is at least 70% but less than 90% of the maximum adjusted overall assessment score; (iii) weak performance is at least 50% but less than 70% of the maximum adjusted overall assessment score; and (iv) low performance is less than 50% of the maximum adjusted overall assessment score.We used this classification scheme to assess both overall performance and individual domains.

Results
The assessment showed that 121 countries (an estimated 55% of the world's population) have civil registration and vital statistics systems of high or moderate performance (Table 2).The system performance was assessed as weak in 30 countries where approximately one quarter of the world's population live.As such, one fifth of people live in 43 countries with the poorest-performing systems.Globally, the average adjusted overall assessment score was 0.699; ranging from 0.361 on average in countries classified as low, to 0.926 on average in countries rated as high performance.More detail on the adjusted overall assessment score for individual countries can be found in the online repository.Fig. 1 shows the classification of countries based on their respective average adjusted overall assessment scores across all domains.
Of the 53 systems with high performance, most were located in the Region of the Americas and European Region, with very few in the Western Pacific or Eastern Mediterranean Regions.Countries in the high category have systems which record all, or almost all, vital events and where it is compulsory for medical doctors to certify causes of death before a death can be registered, and to use rules and standards from the International Statistical Classification of Diseases and Related Health Problems (ICD).
The 68 countries with moderately performing systems manage to record most, or often all, births and deaths but efficiency and data quality are of concern.In many cases, listed causes of death are either incorrectly certified or coded.As a result, confidence in the data is reduced among data users and stakeholders.
Countries classified as having weak system performance register the majority of events that occur in urban areas, hospitals and health facilities.However, outside of cities, deaths, and in particular child deaths, are grossly underreported.Cause of death is often not medically certified nor determined using standard verbal autopsy methods.These challenges are common in the Africa and South-East Asia Regions and among the smaller countries situated in the Region of the Americas and the Western Pacific Region.
Most of the 43 countries classified as having low-performing systems have only recently begun to develop their civil registration and vital statistics systems, and usually only have registration points in urban areas.The data produced by such systems is generally incomplete and does not include cause of death.
More detailed information about the performance of the four categories of countries can be obtained from their scores on each of the four domains of the performance assessment framework (Table 3).Globally, the weakest aspect of all civil registration and vital statis-  Note: Overall performance is an average of the domains: (i) enabling environment for system; (ii) functioning of the system; (iii) health sector contributions to civil registration and vital statistics; (iv) dissemination practices and demand for vital statistics.Countries with a population higher than 1 million were included in the calculation of the maximum score achieved.High performance is designated to countries with an adjusted overall assessment score that is 90% or more of the maximum score; moderate performance is designated to countries with an adjusted overall assessment score that is at least 70% but less than 90% of the maximum score achieved; weak performance is designated to countries with an adjusted overall assessment score that is at least 50% but less than 70% of the maximum score achieved; and low performance is designated to countries with an adjusted overall assessment score that is less than 50% of the maximum score achieved.3).The country data on the average score for each domain is available in the online repository. 19

Discussion
Our results indicate that for 38% of WHO Member States, civil registration and vital statistics system performance is well below the level required for reliably informing policy and programme management.Our results identify a major deficit in domain three (that is, contributions of the health sector to strengthening civil registration and vital statistics systems), particularly in countries with weak-and low-performing systems.Health facilities and community health workers in these countries are frequent points of contact with the population, and could be given greater responsibility for notifying vital events to registration authorities.Similarly, since the diagnostic accuracy and quality of mortality data should be a key concern for the health sector, a more active role of physicians in health institutions in ensuring that the certification practices are of sufficient quality to meet policy needs would be desirable.
1][22] There a substantial body of knowledge that has been accumulated by experts over the years that can be used to improve civil registration and vital statistics practice; we propose a generic progress pathway for each of the four civil registration and vital statistics performance categories that can be adapted to individual country contexts, with key priority actions appropriate for different system performance levels.These are summarized in Table 4.
According to our performance typology, the countries with highperforming systems already have civil registration and vital statistics systems that capture all, or almost all, births and deaths, and ensure that the WHO standard international death certificate is used for certifying the cause.Yet improvements in diagnostic accuracy and specificity are still possible for many of these countries through better training of doctors in correct death certification.Other potential gains could be achieved through routine application of data quality software, for example, ANACONDA (co-developed by the University of Melbourne, Melbourne, Australia and the Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland) to check the accuracy and completeness of mortality and cause of death data. 23Finally, introduction of electronic notification and registration will lead to improved system efficiency in countries where this is not yet available (Table 4).
In the countries where system performance was classified as moderate, most vital events are registered, but quality and timeliness of the cause of death data are often poor due to substandard certification practices among doctors. 24There is often limited awareness by government and health authorities of data deficiencies and hence little interest in conducting data quality reviews.Introduction of electronic data deficiency analysis and introduction of automated ICD coding would dramatically improve the quality of cause of death data and speed up data reporting and dissemination. 25The pathway suggested in Table 4 for this category therefore includes system improvements aimed at more accurate and timely data collection for policy.
Most countries in the weak-and low-performance categories have conducted assessments of their civil registration and vital statistics systems, but frequently only managed to implement a few steps in their improvement plans; often lacking financial, technical and human resources.The differences between their improvement strategies are detailed in Table 4 and, while many actions are similar, their scope will differ according to development level.Experience suggests introducing improvement actions in a stepwise fashion is crucial; initially in a pilot population or area before attempting national implementation.A key priority for countries initiating system development is intersectoral coordination, which can guide implementation and find agreement on specific interventions and development timeframes.
A functioning and efficient system requires a full understanding of all the steps involved in registering vital events, hence the importance of conducting a detailed business process mapping to ensure that all potential synergies in the system are explored, duplications identified and resolved, and problems mitigated.Priority should be given to improving the percentage of all vital  While universal medical certification is not feasible in countries with poorly performing or burgeoning systems, countries should be encouraged to implement validated, cost-efficient verbal autopsy methods that can generate evidence on the leading causes of community deaths.Similarly, the health sector could obligate their facilities to report inpatient births, deaths and causes of deaths on standard forms to registration authorities.If collaborating with local registration authorities, this approach should be relatively easy to implement.
The COVID-19 pandemic disrupted functioning civil registration and vital statistics systems, preventing many countries from reliably estimating deaths, especially in countries where the civil registration and vital statistics system is paper-based and/or dependent on in-person visits. 26One survey revealed that just 24% of countries (16 of 66 countries) had uninterrupted civil registration and vital statistics during the pandemic; while just 73 of 194 (38%) countries had national data complete enough to accurately measure excess mortality. 26,27One positive trend to emerge from the pandemic is the increased use of online registration services to register births and deaths.][30] The primary limitation of our study is the wide range of disparate data sources used to measure civil registration and vital statistics system performance.As they all had some information content, we gave equal weight to each data source.Although we assessed all data accessible to our team, it is likely that more information was available locally that could have had an impact on the adjusted overall assessment scores.As such, the results presented here are likely more pessimistic than reality.Second, data collected for other purposes might not translate perfectly to the indicators contained in our performance assessment framework.As such, they might sometimes only provide an approximate measurement of the domain characteristic under investigation.Furthermore, the date and period of data collection varied by almost a decade (2010 to 2020) across data sources, potentially increasing bias towards more favourable responses from recent data collection efforts.These limitations need to be considered when monitoring the implementation and evaluating the effectiveness of strategies suggested by our framework.
In conclusion, governments need to empower the health sector to become active participants in civil registration and vital statistics systems, especially as they pertain to the notification of births and deaths and cause of death determination.The health community can contribute to the improvement of medical certification practices and coding expertise with automated ICD coding tools.In countries where the majority of individuals die at home without medical supervision, the health sector needs to provide leadership for the implementation of costeffective verbal autopsy methods and other strategies to increase knowledge about leading causes of home death 31 .
The tools, methods and accumulated knowledge and expertise now exist to implement the interventions proposed in the four civil registration and vital statistics improvement pathways.The WHO Civil registration and vital statistics strategic implementation plan, 2021-2025 32 can provide the organizational framework and health sector leadership to facilitate appropriate, best-practice technical assistance to countries, especially those with weakor low-performing systems, to rapidly and sustainably improve performance.While financial resources are vital to this process, real progress will only be made if there is strong leadership and commitment from countries to improve their registration systems in recognition of the health benefits for their populations.■ Bull World Health Organ 2023;101:758-767| doi: http://dx.doi.org/10.2471/BLT.22.289033   Performance of national civil registration and vital statistics systems Lene Mikkelsen et al.

Table 1 . Domains and indicators used for the civil registration and vital statistics performance assessment framework
International statistical classification of diseases and related health problems; WHO: World Health Organization.Bull World Health Organ 2023;101:758-767| doi: http://dx.doi.org/10.2471/BLT.22.289033 ICD:

Table 2 . Stratification of WHO Member States and population according to civil registration and vital statistics system performance categories, 2019 Overall performance level No. of WHO Member States % of global population 11 Average adjusted overall assessment score and range
• High performance: adjusted overall assessment score over 0.871 • Moderate performance: adjusted overall assessment score from 0.677 up to 0.871 • Weak performance: adjusted overall assessment score from 0.484 up to 0.677 • Low performance: adjusted overall assessment score less than 0.484

Table 3 . Number of WHO Member States in each performance category and average adjusted overall assessment score of civil registration and vital statistics systems in each domain, 2019 Domain No. of WHO Member States (average adjusted overall assessment score per domain)
WHO: World Health Organization.Bull World Health Organ 2023;101:758-767| doi: http://dx.doi.org/10.2471/BLT.22.289033Performance of national civil registration and vital statistics systems Lene Mikkelsen et al.

cause of death data practices in health facilities and the community
ICD: International statistical classification of diseases and related health problems.